Vulnerable populations

Innovations

Technology-Facilitated Education and Consultations With Lactation Specialists Triple Breastfeeding Rates Among Low-Income Minority Women in Primary Care Clinics 05/26/14

Obstetrics/gynecology clinics offered electronic medical record–facilitated education, counseling, and support from a lactation consultant to low-income minority women, leading to a threefold increase in breastfeeding rates.

Information Technology-Facilitated Identification of At-Risk Primary Care Patients Combined With In-Office Automated Measurement Significantly Reduces Undiagnosed Hypertension 05/19/14

Primary care practices leverage information technologies to identify patients at risk of undiagnosed hypertension and schedule them for automated office blood pressure measurement, reducing the likelihood of remaining undiagnosed by more than 70 percent.

Daily Text Messages and Nurse Followup Improve Self-Management Behaviors in Patients with Diabetes, Leading to Better Glycemic Control and Lower Costs 04/28/14

Daily automated text messages combined with nurse followup improved self-management behaviors among patients with diabetes, leading to significant improvements in glycemic control, fewer doctor visits, lower costs, and high patient satisfaction.

Managed Care Entity Funded By Public Agencies Reduces Institutionalization and Recidivism, and Improves School Attendance and Functional Ability Among Emotionally Disturbed Youth 03/30/14

Funded by and receiving referrals from the various public systems serving at-risk youth, Wraparound Milwaukee pays for and supports the provision of coordinated mental health and support services to children and adolescents with serious emotional and mental health needs, leading to less institutionalization and recidivism, lower costs, increased school attendance, better functioning at home and in school, and high satisfaction.

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.

Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies 03/17/14

After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.

State Provides Financial and Technical Support to Underserved Communities Designated as Health Enterprise Zones, Leading to Enhancements in Primary Care Capacity 03/11/14

The State of Maryland provides financial and technical support to five communities designated through a competitive bidding process as health enterprise zones, leading to an expansion of primary care capacity in these areas.

State Medicaid Program Pays Additional Capitated Fee to Integrated Primary Care and Mental Health Homes, Leading to Better Outcomes and Lower Costs 03/01/14

The Missouri Medicaid Health Home program provides capitated payments to primary care and mental health medical homes that adopt an integrated staffing model that allows patients to receive both medical and mental health care, leading to better health outcomes and lower utilization and costs.

Community Health Workers Offer Culturally Tailored Interactive Workshops and Counseling to Filipino Americans, Leading to Improvements in Medication Adherence and Cardiovascular Risk Factors 02/28/14

Community health workers provided culturally tailored workshops and one-on-one counseling and support to Filipino Americans at high risk of cardiovascular disease, leading to greater adherence to medication regimens, better attendance at scheduled appointments, improved blood pressure control, and lower body mass index.

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